2.

hours

Continuing Education

The Use of Algorithms

in Assessing and Managing

Persistent Pain in Older Adults

An introduction to tools that can facilitate
the application of research to practice.
By Anita M. Jablonski, PhD, RN,
Anna R. DuPen, MN, ARNP, ACHPN,
andMary Ersek, PhD, RN, FAAN

Overview: As the U.S. population

ages, nurses will care for increas
ingnumbers of older adults, most
ofwhom suffer from at least one
chronic illness. The persistent pain
associated with many chronic ill
nesses can have detrimental effects
on patients functioning and quality
of life. Algorithms developed from
evidence-based clinical practice
guidelines are tools that can facili
tatethe application of research to
practice. This article introduces
readers to the use of algorithms in
guiding the assessment and man
agement of persistent pain in older
adults, and provides an illustrative
case study.
Keywords: algorithm, clinical
decision making, clinical practice
guidelines, evidence-based practice,
nursing judgment, older adults, pain
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ts no secret that greater numbers of Americans are

living longer than ever; and with advancing age,
many will find themselves dealing with persistent,
often debilitating pain. Nurses in all health care set
tings can expect to be caring for increasing numbers
of such patients. Yet experts acknowledge that pain in
older adults often goes underrecognized and under
treated.1 Algorithmsstep-by-step guidesfor pain
assessment and management might help nurses and
other clinicians begin to change this situation.
Over the last 50 years, the average life expectancy
for a U.S. citizen has increased from 69.7 to 77.9 years,
according to the Centers for Disease Control and Pre
vention.2, 3 The proportion of citizens ages 65 years and
older is also rising; experts predict that by 2030, older
adults will constitute 20% of the populationabout
71 million people.4 Moreover, about 80% of older
Americans are now living with at least one chronic ill
ness.4 For older adults, the persistent pain often asso
ciated with chronic illnesses is of particular concern
because of its detrimental effects on functioning and
quality of life.
Research indicates that there is a high prevalence
of persistent pain among both community-dwelling
older adults and nursing home residents.5-7 Pain associ
ated with osteoarthritis of the hand,8 back,9 and hip and
knee joints10, 11 plays a major role in significant func
tional decline in older adults. A study in people ages
80 and older who reported daily pain from various
conditions found that, as pain severity increased, mus
cle strength and physical performance progressively
declined.12 Another recent study found that older adults
who have persistent pain are at increased risk for falls;
the association held even after researchers adjusted
for underlying chronic illness and its treatment.13 This
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Figure 1. Pain Assessment Algorithm

Can the patient

give self-report?

Yes

No

If pain is mild to
moderate, go to
the APAP
Algorithm
Conduct
initial pain
assessment

Go to the Pain
Assessment in
Nonverbal
Patient Algorithm

No

Reassess
as
appropriate

Go to the
Neuropathic Pain
Treatment
Algorithm

If pain is
moderate to
severe, go to the
Opioids
Algorithm

and

and

If pain is moderate
to severe, go to the
Opioids Algorithm

If pain is from
acute inflammation or bony
metastases, go to
the NSAIDs
Algorithm

Yes

Yes
Yes

Treat the
etiology as well
as the pain

Does
treatment
resolve
the pain?

Is the patient
currently
(in past 7 days)
experiencing any
type of pain?

or

Is the pain a
result of a
treatable etiology
(such as a
UTI)?

If pain is
MIXED
If pain is
NOCICEPTIVE

If pain is
NEUROPATHIC

No

Conduct pain
character
assessment

No

APAP = acetaminophen; NSAIDs = nonsteroidal antiinflammatory agents; UTI = urinary tract infection.

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35

is significant because falls are known to be a leading

cause of death and disability in the older popula
tion.14,15
Since nurses spend more time caring for older
adults, in both community and residential settings,
than do other health care professionals, they can be
pivotal in ensuring that their patients pain is effectively
assessed and managed. A nurses success in doing so
will depend on various factors, including her or his
comprehensive assessment skills; knowledge of ap
propriate, evidence-based treatment strategies; and
decision-making ability. But basic nursing programs
often dont adequately prepare nurses to care for older
adults or train them in how to apply best evidence to
practice.16, 17
Algorithms developed from evidence-based clini
cal practice guidelines such as those published by the
American Geriatrics Society (AGS) and the American
Medical Directors Association (AMDA) are tools that
can support and enhance nurses efforts to assess and
manage persistent pain in older adults. Although al
gorithms are frequently used by both physicians and
nurses as aids in clinical decision making,18, 19 more ex
tensive use might facilitate the application of best re
search evidence to practice. This article describes what
algorithms are and outlines their advantages and po
tential drawbacks when used in clinical practice. Two
algorithms that focus on pain assessment and treat
ment with opioids are presented, along with an illus
trative case.

algorithm shown in Figure 1 will find a set of sequen

tial questions and instructions. Each question can be
answered yes or no; each answer directs the user
along a particular path and ultimately to a specific, rec
ommended action.
Advantages. Nurses make numerous decisions
every day in clinical practice, the consequences of
which directly affect outcomes of care. Because algo
rithms guide thinking in a logical, step-by-step ap
proach, they can be used to refine nurses skills in
decision making, and can help to reveal gaps in a par
ticular assessment or management process, as well as
errors in thinking about a clinical problem.18, 20 Algo
rithms can be especially valuable for novice nurses who
have less experience in decision making: they can help
the nurse to make sound decisions and avoid flawed
ones, thereby increasing her or his confidence.
Many nurses havent been adequately prepared to
locate, interpret, and apply research findings and clini
cal guidelines to practice.21 Algorithms can be valuable
teaching aids in addressing these deficits. Their visual,
flow-diagram format has been shown to be effective
in promoting learning and adherence to best prac
tice.18, 19, 22
Lastly, algorithms can reveal areas in which further
research is needed. In an algorithm based on clinical
practice guidelines, the recommendations made at var
ious decision points will be supported by various levels
of evidence. For example, the AGSs guidelines for the
pharmacologic management of persistent pain in older

Algorithms step-by-step approach can be used to refine nurses

skills in decision making.
ALGORITHMS: AN OVERVIEW

Clinical practice guidelines are derived from rigorous

systematic reviews of the current literature; they syn
thesize scientific evidence and expert opinion into rec
ommendations for best practice. But it may not be im
mediately clear to a practitioner how to best implement
those recommendations. Algorithms offer clinicians a
method for doing just that.
An algorithm is a formula or set of rules for solving
a problem, according to Tabers Cyclopedic Medical
Dictionary; Stedmans Electronic Medical Dictionary
defines the term as a systematic process consisting of
an ordered sequence of steps, each step depending on
the outcome of the previous one. An algorithm can
guide the assessment or management of a given clinical
problem, define the possible end points, and help the
nurse to determine the best course of action. Typically
an algorithm is presented as a flow diagram, with sev
eral branching pathways that lead to specified end
points.18 For example, a nurse using the pain assessment
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adults advise that nonsteroidal antiinflammatory drugs

(NSAIDs) be prescribed rarely, and with extreme cau
tion, in highly selected individuals; the recommenda
tion is based on strong, high-quality evidence such as
that from randomized controlled trials.5, 23 But sup
port for the use of nonpharmacologic methods (such
as the application of heat or cold, acupuncture, and
transcutaneous electrical nerve stimulation) is much
weaker, based on expert opinion or clinicians expe
rience.23 An algorithm derived from these guidelines
will reflect such differences in the strength and quality
of evidence, thus underscoring gaps and weaknesses
in the knowledge base.
Drawbacks and caveats. Critics have argued that
algorithms are rigid and encourage robotic decision
making.18 Some contend that algorithms dont take
into account all possible factors, such as comorbidities,
medical and social histories, and potential drug-drug
interactions, that must be considered in making clin
ical decisions about treatment.18
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But its not feasible to build all possible contingen

cies into an algorithm. An algorithm is designed to
cover the likely contingencies for the majority of pa
tients with a given condition; still, individual differences
must be considered. Moreover, to ensure high-quality
care, patient preferences and values must also be in
corporated into evidence-based practice.24
Finally, a given algorithmlike the practice guide
lines its based uponcan only be as strong as the un
derlying evidence. Although many recommendations
will have been validated with high-quality, strong em
pirical evidence, others may necessarily be based on
weaker evidence such as expert opinion. Thus, its im
portant to emphasize that sound decision making isnt
a rote process; and that while algorithms can be excel
lent guides for clinical decision making, they cannot
substitute for careful observation and critical thinking.
TWO ALGORITHMS FOR ADDRESSING PAIN IN OLDER ADULTS

Two algorithms, one focusing on pain assessment and

one on opioid therapy, are presented in Figures 1 and
2. They are from a series of algorithms developed for
a study, funded by the National Institutes of Health
(NIH), to evaluate the efficacy of algorithms in assess
ing and managing pain in older adults who reside in
nursing homes. (All of us were involved in this study:
ME was the primary investigator and AMJ and ARD
were coinvestigators.) Each algorithm in the series ad
dresses a major aspect of pain assessment and man
agement. There are separate algorithms for assessing
pain in people who can and cannot self-report. There
are also algorithms to guide the use of specific types of
analgesics (such as acetaminophen, NSAIDs, opioids,
and adjuvant medications), as well as to guide assess
ment and management of analgesic-related adverse ef
fects (such as constipation, sedation, and nausea and
vomiting).
The algorithms are based on the relevant, evidencebased clinical practice guidelines developed by the
AGS and the AMDA.5, 23, 25 A panel of experts in geri
atrics and pain reviewed the initial drafts, and the final
drafts were revised based on their critiques. First de
veloped in 2005, the algorithms were most recently up
dated in 2009. All of the algorithms were compiled in
a reference manual and were tested during the interven
tion arm of the study. The study has been completed
and data analysis is ongoing.
ILLUSTRATIVE CASE

Helen Gordon, an 80-year-old resident in a long-term

care facility, suffers from several chronic illnesses,
including chronic renal failure; hypertension; osteo
porosis; and osteoarthritis, a progressive degenerative
joint disease that affects several of the patients joints,
particularly her knees. (This case is a composite based
on our experience.) Until recently, she was able to walk
using a walker. But during the past week, Ms. Gor
don has frequently reported pain. She now relies on

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Basic Elements of Pain Assessment

Location
Intensity
Pattern (for example: constant, intermittent)
Duration
Character (for example: sharp, burning, aching)
Effect on physical functioning and mobility
Effect on mood, social functioning, and sleep
Factors that exacerbate and alleviate
Current treatment regimen
Adverse effects of therapy

a wheelchair to get around and requires moderate as

sistance with transfers.
The nurse caring for Ms. Gordon recognizes that
pain is a significant factor in her patients limited mo
bility. The nurse isnt sure which treatment will be
most effective in helping Ms. Gordon to regain her
previous level of independence. The first step toward
managing her pain is a thorough pain assessment. The
nurse refers to the algorithm shown in Figure 1 to
guide the assessment, beginning with the oval shape
in the upper left-hand corner.
Pain assessment algorithm. Can the patient give
self-report? Answer: Yes.
As directed by the algorithm, the nurse first deter
mines that Ms. Gordon is alert and oriented and able
to report her pain. The algorithm next instructs the
nurse to conduct an initial pain assessment. If Ms.
Gordon had been unable to self-report, the algorithm
would have directed the nurse to use an algorithm de
signed for patients unable to self-report.
Is the patient currently (in past 7 days) experiencing any type of pain? Answer: Yes.
The nurses assessment, which includes a physical
examination and patient interview, reveals that Ms.
Gordon is experiencing moderate-to-severe, nonradi
ating, bilateral knee pain. Ms. Gordon reports that,
until recently, this pain was mild to moderate and tol
erable; but during the past week its increased mark
edly. Asked to rate her current pain on a 0-to-10 scale,
with 0 representing no pain and 10 representing the
worst pain imaginable, Ms. Gordon rates her current
pain at 6; she adds that its usually worse in the morn
ing, often at 7 or 8. The pain is exacerbated with exces
sive movement and prolonged periods of immobility.
Ms. Gordon is distressed by the adverse effect this pain
is having on her ability to function independently; for
example, shes having difficulty showering and walk
ing to meals. She states that shes depressed because
the acetaminophen shes been taking is no longer ef
fectively relieving her pain.
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Is the pain a result of a treatable etiology? Answer:

No.
The nurse asks Ms. Gordon whether shes fallen
or experienced other physical trauma in the last two
weeks; Ms. Gordon says that she hasnt. She also states
that although the intensity of her pain seems to be
worsening, its location and quality are unchanged. The
findings of the nurses physical examination are consis
tent with Ms. Gordons known history, and a review of
the medical record (X-ray reports, physician notes) re
veals no evidence that Ms. Gordons pain results from
a new or treatable source. The nurse concludes that the
pain is probably the result of worsening osteoarthritis.
Ms. Gordon receives medications for osteoporosis and
restorative therapies (including physical therapy and
massage) to slow the functional impact of osteoarthri
tis, but neither condition is curable.

impairs function, or both. Ms. Gordon is already tak

ing up to 3 g of acetaminophen daily without satisfac
tory pain relief. She also rates her pain as greater than
4 and has decreased function because of pain. Thus
the nurse determines that she may indeed require opi
oids to achieve effective pain relief, and continues to
the next step of the opioids algorithm.
Is the pain localized and affecting superficial structures? Answer: Yes.
Superficial structuresstructures relatively close to
the bodys surfacecould include skin, mucous mem
branes, subcutaneous tissue, and superficial tendons
and ligaments. Ms. Gordons pain is nociceptive and
localized in her knees, possibly as a result of increased
inflammation around the joints.
Has the patient been tried on topical analgesics?
Answer: No.

The information gleaned from a thorough pain assessment will

help to determine the appropriate treatment regimen.
As the algorithm indicates, the next step is for the
nurse to further evaluate the character of Ms. Gordons
pain. (See Basic Elements of Pain Assessment.) This
step is crucial: the information gleaned from a system
atic and thorough pain assessment will help to deter
mine the appropriate treatment regimen, particularly
with regard to analgesics.
Conduct pain character assessment: is the pain noci
ceptive, neuropathic, or mixed? Answer: Nociceptive.
Knowing what type of pain a patient is experiencing
is crucial for both identifying its likely source and de
termining the appropriate treatment. Nociceptive pain,
which is caused by damage to somatic tissue (such as
bones or muscle) or visceral tissue (such as the lungs
or bladder), is treated differently from neuropathic
pain, which is caused by damage to the peripheral or
central nervous system. (See Table 1 for a comparison
of nociceptive and neuropathic pain.) Ms. Gordon de
scribes the pain as a deep ache in her knees; she denies
having any burning, numbness, tingling, or shooting
pain. Based on the character and location of Ms. Gor
dons pain, the nurse determines that its nociceptive,
caused by the osteoarthritis in her knees. The pain as
sessment algorithm next directs the nurse to an appro
priate pain management algorithm. In Ms. Gordons
case, because shes experiencing nociceptive pain that
she rates as moderate to severe, the nurse is referred
to the opioids algorithm shown in Figure 2.
Opioids algorithm. The opioids algorithm begins
with a box outlining criteria for its use: the patient
must be on an optimized acetaminophen (abbreviated
APAP) regimen and must have either moderate-to-
severe pain (4 or greater on a 0-to-10 scale), pain that
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Because Ms. Gordons pain is nociceptive and local

ized in her knee joints, it may respond well to topical
analgesics, which havent yet been tried. The algorithm
recommends that a trial of certain agents be initiated
and the patient subsequently reassessed. The nurse ob
tains an order for a trial of a topical NSAID, diclo
fenac sodium 1% gel, to be applied to both knees three
times a day.
The strength of the evidence for some elements of
the algorithm varies, as is the case here. Several top
ical agents can be used to treat pain, including lido
caine (Lidoderm and others), capsaicin (Capsagel and
others), and NSAIDs; topical preparations include
creams, gels, and patches. In general, strong evidence
supporting the use of topical analgesics, particularly for
nonneuropathic pain, is lacking.5 But there is some evi
dence for the short-term efficacy of topical NSAIDs,26-28
although long-term efficacy hasnt been established.29
Of the topical NSAIDs, preparations of diclofenac and
ibuprofen have been the most widely studied.26
The algorithm recommends an initial trial of a top
ical analgesic because they tend to have fewer adverse
effects and to interact less with other drugs than do sys
temic analgesics, making their use an advantage, espe
cially in elderly people, who are more likely to have
multiple comorbidities for which they are receiving
pharmacotherapy.26, 28 More research is needed to clar
ify the proper role of these agents in managing pain.
An order for diclofenac gel is faxed to the institu
tions contract pharmacy; but this agent isnt on the
pharmacys preferred formulary, so the recommen
dation cannot be acted on. This barrier points out the
need for critical thinking when using an algorithm.
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Figure 2. Opioids Algorithm

Patient is optimized
on APAP

Reassess
as
appropriate

and has
Moderate-to-severe pain
(4 or greater on 0-to-10 scale)
and/or has
Pain that impairs function

Conduct pain pattern

assessment; switch to
a long-acting opioid
for constant pain

Go to the Opioids
Upward Titration
Algorithm
Is the pain
localized
and affecting
superficial
structures?

No
No

Yes

Yes
Go to the NSAIDs
Algorithm
Has the
patient been
tried on topical
analgesics?

No

Yes

Is the patient
currently
taking
opioids?

Yes

Is pain
controlled?

Initiate nondrug
strategies
No

Does
the patient
have persistent,
unacceptable
adverse effects?

No
Yes

Initiate a trial
of capsaicin or
NSAIDs cream or
gel, or lidocaine
patch, and
reassess

Initiate a short-acting
opioid at starting dose
Reassess after each
dose

APAP = acetaminophen; NSAIDs = nonsteroidal antiinflammatory agents.

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Other contingencies might include a history of drug

allergy or an earlier trial of a drug that resulted in intol
erable adverse effects or inadequate analgesia. In such
circumstances, the nurse can ask the consulting phar
macist to investigate alternatives. In this case, she asks
whether there is a similar topical medication on the
pharmacys formulary, but none is found, and she
moves on to the next step of the algorithm.
Is the patient currently taking opioids? Answer: No.
Since Ms. Gordons pain is moderate to severe and
she isnt currently taking opioids, the algorithm ad
vises beginning with a short-acting opioid. Such use is
suggested because short-acting opioids can be titrated
for pain relief more rapidly and safely than can longacting opioids.30 The starting dose of a short-acting
opioid may be less than the lowest available amount
of a long-acting opioid, allowing more gradual titra
tion upward and lessening the likelihood of toxicity.

Does the patient have persistent, unacceptable ad

verse effects? Answer: No.
The algorithm recommends that after each dose of
a new opioid, the nurse reassess the patients pain level
and monitor for adverse effects. (The nurse would also
consult the separate algorithm for preventing and man
aging adverse effects of pain medications, not shown
in this article.) In this case, knowing that constipation
is a common adverse effect with opioids, the nurse also
requests an order for a stool softener and a stimulant
laxative. During the initial 72 hours, Ms. Gordon takes
oxycodone 2.5 mg each morning upon awakening,
when her pain is worst, and every four to six hours
as needed thereafter. She experiences mild drowsiness
with the first dose of oxycodone but not with subse
quent doses. The nurse administers the stool softener
and laxative as ordered also, and Ms. Gordon main
tains her usual daily bowel movement.

While algorithms provide a logical approach to decision making,

they cannot replace critical thinking.
This is an especially important consideration in Ms.
Gordons case, given her chronic renal failure. Also,
short-acting opioids have shorter half-lives; should
adverse effects occur, those associated with short-
acting opioids can be managed more quickly than can
those associated with long-acting opioids.
After completing a thorough assessment, to ensure
optimum communication, the nurse uses the Situation,
Background, Assessment, and Recommendation Re
port to a Physician tool31 when consulting with Ms.
Gordons physician. In describing the situation, the
nurse reports that Ms. Gordon is experiencing worsen
ing and unrelieved pain in her knees. The nurse pro
vides background information, including Ms. Gordons
medical history and current drug regimen, noting that
her pain medications are no longer effectively reliev
ing her pain. The nurse also reports the pain assess
ment data and the algorithms recommendation to
initiate a short-acting opioid, to be taken as needed.
Persistent pain in older adults is often undertreated
because of fears of oversedation, functional depen
dence, and addiction.32, 33 Anticipating that the physi
cian might be reluctant to prescribe an opioid for Ms.
Gordon, the nurse explains the rationale for doing so,
drawing on her knowledge of the literature. After con
sidering the relevant literature and discussing the pros
and cons of opioid therapy with the nurse, the physi
cian orders oral oxycodone 2.5 mg every four to six
hours as needed, a dosage consistent with AGS guide
lines.5 The physician also requests that the nurse peri
odically reevaluate Ms. Gordons pain level and ad
verse effects, and report back by fax in 72 hours.
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Is the pain controlled? Answer: No.

Successful pain management involves finding an
analgesia regimen that delivers maximum pain relief
with minimal adverse effects. In some cases, a drugs
adverse effects such as nausea and vomiting may be
immediate and severe, and the drug may have to be
stopped before the team can determine its effective
ness in relieving pain. In other cases, adverse effects
may be milder and can be managed, allowing suffi
cient opportunity for the team to make that determi
nation.
On the third day of the new regimen, the nurse
again reviews the intensity and pattern of Ms. Gordons
pain. Ms. Gordon has indicated that on this regimen
her usual pain has decreasedshe rates it at 3 on the
0-to-10 scalebut her morning pain remains mod
erate to severe. Thus her pain is fairly constant over
all but tends to worsen in the morning. This pattern is
generally best managed with round-the-clock dosing
with a short-acting opioid for constant pain, plus an
additional dose for episodes of worsened pain. Be
cause the exacerbation occurs regularly and predict
ably, the additional dose should be scheduled (rather
than taken as needed).
The nurse faxes the physician the updated pain as
sessment along with suggested changes to the regimen.
Together they consult the opioids upward titration
algorithm, which directs them to increase the dose by
25% to 50%. They elect to schedule a 5-mg dose of
oxycodone once daily in the early morning, with sub
sequent 2.5-mg doses at midday and at bedtime. Af
ter two days on this amended regimen, Ms. Gordon
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Table 1. Comparison of Nociceptive and Neuropathic Pain

Nociceptive Pain

Neuropathic Pain

Definition

Normal processing of stimulus that

damages normal tissue or has the
potential to do so if prolonged.

Abnormal processing of sensory input by

the peripheral or central nervous system.

Types

Superficial somatic painarises from

skin, mucous membranes, subcutane
ous tissue; tends to be well localized.
Examples: sunburn, skin contusions

Central paincaused by primary lesion or

dysfunction in the central nervous system.
Examples: poststroke pain, pain associ
ated with multiple sclerosis

Deep somatic painarises from mus

cles, fasciae, bones, or tendons; local
ized or diffuse and radiating.
Examples: arthritis, tendonitis, myofas
cial pain

Peripheral neuropathiesfelt along the

distribution of one or many peripheral
nerves; caused by damage to the nerve.
Examples: diabetic neuropathy, alcoholic
or nutritional polyneuropathy, trigeminal
neuralgia, postherpetic neuralgia

Visceral painarises from visceral

organs, such as the GI tract or bladder;
well or poorly localized; often referred to
cutaneous sites.
Examples: appendicitis, pancreatitis,
cancer affecting internal organs

Deafferentation painresults from a loss

of afferent input.
Examples: phantom limb pain, postmas
tectomy pain
Sympathetically maintained painper
sists secondary to sympathetic nervous
system activity.
Examples: phantom limb pain, complex
regional pain syndromes

Character
(how pain is
typically
described)

Aching, throbbing, cramping, dull,

sharp, tender.

Shooting, electric-like, burning, stabbing,

pins and needles.

Treatment

Usually responsive to nonopioid drugs,

opioid drugs, or both.

Usually includes adjuvant analgesics. For

example:
topical agents such as capsaicin (Cap
sagel and others), lidocaine (Lidoderm
and others)
anticonvulsants such as gabapentin
(Neurontin), pregabalin (Lyrica)
tricyclic antidepressants such as desi
pramine (Norpramin), nortriptyline
(Pamelor, Aventyl)
alternative antidepressants such as ven
lafaxine (Effexor), bupropion (Wellbutrin
and others)

GI = gastrointestinal.

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rates her usual pain at 3 and her morning pain at 2 or

3. Although she reports feeling a bit sleepy after the
morning dose, she doesnt want to change it because
its effectively relieving her pain. She adds that shes de
lighted that she can again walk to breakfast.
The question Is the pain controlled? now yields a
yes answer. At this point, the opioids algorithm indi
cates that a switch from a short-acting opioid to a
long-acting opioid might be warranted. There is evi
dence that older adults who require more than four
doses of a short-acting opioid daily to manage con
stant pain might benefit from such a change. In a study
of more than 10,000 nursing home residents with per
sistent pain, long-acting opioids were found to be supe
rior to short-acting opioids in improving function and
increasing social engagement.34 Another study found
that sleep quality improved when long-acting opi
oidswere substituted for short-acting opioids.35 Use of
long-acting opioids may also improve adherence to the
dosing schedule,36 as well as allowing patients to spend
less time focusing on pain and pain management and
more time focusing on other aspects of their lives.36, 37
Its unclear, however, whether long-acting opioids
are superior to short-acting opioids in relieving pain.30,36
This aspect of pain management requires further study.
Although both short-acting and long-acting opioids
play important roles in pain management,30 critical
thinking and a thorough assessment of the pain pat
tern and the effects of pain on the patients quality of
life are crucial to evaluating which of the two types of
drugs (or both) should be used.
Since Ms. Gordon is taking at least three doses of
the short-acting opioid daily, the nurse discusses chang
ing to a long-acting opioid. Ms. Gordon is happy with
the pain relief she obtains on the current regimen and
says she doesnt want to change medications at this
time. The nurse plans to reassess her pain pattern over
the next few days. If Ms. Gordon has breakthrough
pain requiring additional doses of the short-acting opi
oid, the nurse may again suggest switching to a longacting opioid.

conclude that a trial of a short-acting opioid was the

appropriate next step in achieving better pain relief.
The opioids algorithm helped the nurse to further re
fine that trial. But its essential to remember that while
algorithms provide a logical approach to decision mak
ing, they cannot replace critical thinking and individ
ualized patient care.
The illustrative case presented here is relatively un
complicated; in clinical practice, some cases will prove
more complex. For instance, some patients might re
quire multiple trials of increasing doses of analgesics
or additional drugs for specific types of pain, such as
neuropathic pain. Some patients may experience ad
verse effects from analgesia that will require assess
ment and management. (As noted earlier, for the NIH
study we developed algorithms for many of these con
tingencies.)
Research indicates that nurses (and other clinicians)
often have inadequate knowledge about how to assess
pain and about the medications used to treat pain.1, 33
In light of these knowledge deficits, algorithms are
probably best presented in a class or in-service training
along with resource materials that provide basic pain
assessment and management information. In the afore
mentioned NIH study, we tested the efficacy of a com
prehensive approach: nurses in both the control and
intervention groups received education in pain assess
ment and management, but those in the intervention
group also received instruction in the use of the algo
rithms and expert support; data analysis is still on
going. Another approach under investigation is the use
of Web-based versions of the algorithms, with embed
ded links to additional resources. Lastly, although our
focus has been on the use of algorithms in pain assess
ment and management, nursing research aimed at de
veloping and testing the use of algorithms for other
aspects of patient care is also indicated. t
For 18 additional continuing nursing educa
tionarticles on the topic of pain, go to www.
nursingcenter.com/ce.

FURTHER EDUCATION AND RESEARCH

The pain assessment algorithm that Ms. Gordons

nurse consulted guided the assessment and led her to

Resources
American Geriatrics Society
www.americangeriatrics.org
Free clinical practice guidelines.
American Medical Directors Association
www.amda.com
Clinical practice guidelines are available for a fee.
42

AJN March 2011

Vol. 111, No. 3

Anita M. Jablonski is an associate professor at the Seattle Uni

versity College of Nursing. At the time of this writing, Anna R.
DuPen was an advanced NP at the Hospice of Kitsap County,
Bremerton, WA; currently shes a palliative care NP at the Palli
ative Care Consultation Service in the Department of Family Med
icine at the University of Washington in Seattle. Mary Ersek is
associate director of the Center for Integrative Science in Aging
and of the John A. Hartford Center of Geriatric Nursing Excel
lence, as well as an associate professor in the School of Nursing,
at the University of Pennsylvania in Philadelphia. Previously she
was director of research at the Center for Nursing Excellence, as
well as a research scientist, at Swedish Medical Center in Seattle.
Contact author: Anita M. Jablonski, jablonsk@seattleu.edu. The
research and development of the algorithms discussed herein were
supported by funding from the National Institutes of Health, Na
tional Institute of Nursing Research (grant No. R01-NR009100).
The authors of this article have disclosed no significant ties,
ajnonline.com

financial or otherwise, to any company that might have an interest in the publication of this educational activity.

REFERENCES

1. Fink R, Gates R. Pain assessment. In: Ferrell B, Coyle N,

editors. Textbook of palliative nursing. 2nd ed. New York:

Oxford University Press; 2006. p. 97-131.
2. National Center for Health Statistics. QuickStats: average
life expectancy at birth, by race and sexUnited States, 2000,
2006, and 2007. Hyattsville, MD: Centers for Disease Con
trol and Prevention; 2009.
3. Xu J, et al. Deaths: preliminary data for 2007. Natl Vital Stat
Rep 2009;58(1). http://www.cdc.gov/nchs/data/nvsr/nvsr58/
nvsr58_01.pdf.
4. Centers for Disease Control and Prevention and the Merck
Company Foundation. The state of aging and health in
America 2007. Whitehouse Station, NJ: The Merck Com
pany Foundation; 2007. http://www.cdc.gov/Aging/pdf/
saha_2007.pdf.
5. American Geriatrics Society, Panel on Pharmacological Man
agement of Persistent Pain in Older Persons. Pharmacological
management of persistent pain in older persons. J Am Geriatr
Soc 2009;57(8):1331-46.
6. McCarthy LH, et al. Chronic pain and obesity in elderly peo
ple: results from the Einstein aging study. J Am Geriatr Soc
2009;57(1):115-9.
7. Won AB, et al. Persistent nonmalignant pain and analgesic
prescribing patterns in elderly nursing home residents. J Am
Geriatr Soc 2004;52(6):867-74.
8. Zhang Y, et al. Prevalence of symptomatic hand osteoarthri
tis and its impact on functional status among the elderly:
theFramingham Study. Am J Epidemiol 2002;156(11):
1021-7.
9. Weiner DK, et al. How does low back pain impact physical
function in independent, well-functioning older adults? Evi
dence from the Health ABC Cohort and implications for the
future. Pain Med 2003;4(4):311-20.
10. Dawson J, et al. Epidemiology of hip and knee pain and its
impact on overall health status in older adults. Rheumatology
(Oxford) 2004;43(4):497-504.
11. Jinks C, et al. Osteoarthritis as a public health problem: the
impact of developing knee pain on physical function in adults
living in the community: (KNEST 3). Rheumatology (Oxford)
2007;46(5):877-81.
12. Onder G, et al. Association between daily pain and physi
calfunction among old-old adults living in the community:
results from the ilSIRENTE study. Pain 2006;121(1-2):53-9.
13. Leveille SG, et al. Chronic musculoskeletal pain and the oc
currence of falls in an older population. JAMA 2009;302(20):
2214-21.
14. Gorina Y, et al. Trends in causes of death among older persons in the United States. Hyattsville, MD: National Center
for Health Statistics, Centers for Disease Control and Preven
tion; 2006. Aging trends, no. 6; http://www.cdc.gov/nchs/
data/ahcd/agingtrends/06olderpersons.pdf.
15. World Health Organization. Physical activity and older adults:
recommended levels of physical activity for adults aged 65
and above. n.d. http://www.who.int/dietphysicalactivity/
factsheet_olderadults/en/index.html.
16. Institute of Medicine, Committee on the Future Health Care
Workforce for Older Americans. Retooling for an aging
America: building the health care workforce. Washington,
DC: National Academies Press; 2008. http://books.nap.edu/
catalog.php?record_id=12089.
17. McConnell ES, et al. Teaching evidence-based nursing prac
tice in geriatric care settings: the geriatric nursing innova
tions through education institute. J Gerontol Nurs 2009;
35(4):26-33.

ajn@wolterskluwer.com

18. Hadorn DC. Use of algorithms in clinical guideline develop

ment. In: McCormick KA, et al, editors. Clinical practice
guideline development: methodology perspectives. Rockville,
MD: Agency for Health Care Policy and Research; 1994.
p.93-104. http://www.acponline.org/clinical_information/
guidelines/process/algorithms/hadorn.pdf.
19. Society for Medical Decision Making, Committee on Stan
dardization of Clinical Algorithms. Proposal for clinical al
gorithm standards. Society for Medical Decision Making
Committee on Standardization of Clinical Algorithms. Med
Decis Making 1992;12(2):149-54.
20. Siddall PJ, Middleton JW. A proposed algorithm for the man
agement of pain following spinal cord injury. Spinal Cord
2006;44(2):67-77.
21. Pravikoff DS, et al. Readiness of U.S. nurses for evidencebased practice. Am J Nurs 2005;105(9):40-51.
22. Du Pen AR, et al. An educational implementation of a can
cer pain algorithm for ambulatory care. Pain Manag Nurs
2000;1(4):116-28.
23. American Geriatrics Society, Panel on Pharmacological Man
agement of Persistent Pain in Older Persons. The manage
ment of persistent pain in older persons. J Am Geriatr Soc
2002;50(6 Suppl):S205-S224.
24. Melnyk BM, Fineout-Overholt E. Consumer preferences and
values as an integral key to evidence-based practice. Nurs Adm
Q 2006;30(2):123-7.
25. American Medical Directors Association. Clinical practice
guideline: pain management. Columbia, MD; 2009. http://
www.amda.com/tools/guidelines.cfm#chronicpain.
26. Agency for Healthcare Research and Quality, U.S. Depart
ment of Health and Human Services. Choosing nonopioid
analgesics for osteoarthritis: clinician summary guide. J Pain
Palliat Care Pharmacother 2009;23(4):433-57.
27. Heyneman CA, et al. Oral versus topical NSAIDs in rheu
matic diseases: a comparison. Drugs 2000;60(3):555-74.
28. McCleane G. Topical analgesic agents. Clin Geriatr Med
2008;24(2):299-312, vii.
29. Lin J, et al. Efficacy of topical non-steroidal anti-inflamma
tory drugs in the treatment of osteoarthritis: meta-analysis
of randomised controlled trials. BMJ 2004;329(7461):
324.
30. Fine PG, et al. Long-acting opioids and short-acting opioids:
appropriate use in chronic pain management. Pain Med 2009;
10 Suppl 2:S79-S88.
31. Haig KM, et al. SBAR: a shared mental model for improv
ing communication between clinicians. Jt Comm J Qual
Patient Saf 2006;32(3):167-75.
32. Kaasalainen S, et al. Pain management decision making among
long-term care physicians and nurses. West J Nurs Res 2007;
29(5):561-80; discussion, 81-8.
33. Weiner DK, Rudy TE. Attitudinal barriers to effective treat
ment of persistent pain in nursing home residents. J Am Ger
iatr Soc 2002;50(12):2035-40.
34. Won A, et al. Long-term effects of analgesics in a popula
tionof elderly nursing home residents with persistent non
malignant pain. J Gerontol A Biol Sci Med Sci 2006;61(2):
165-9.
35. Caldwell JR, et al. Treatment of osteoarthritis pain with con
trolled release oxycodone or fixed combination oxycodone
plus acetaminophen added to nonsteroidal antiinflammatory
drugs: a double blind, randomized, multicenter, placebo con
trolled trial. J Rheumatol 1999;26(4):862-9.
36. Rauck RL. What is the case for prescribing long-acting opi
oids over short-acting opioids for patients with chronic pain?
A critical review. Pain Pract 2009;9(6):468-79.
37. Vallerand AH. The use of long-acting opioids in chronic
pain management. Nurs Clin North Am 2003;38(3):
435-45.

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